Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in family medicine. Your next patient is a 55-year-old female called Kelly Duke, presenting with a lesion on the cheek. Please take a history and perform an appropriate examination.
Patient History:
Kelly Duke, 55-year-old female gym owner.
Last week you noticed a fast-growing lesion on your left cheek. It looks scaly on the top and has bits on the top. It can bleed sometimes. No other discharge. It can be tender when you touch it. It is not itchy or pigmentated. No previous injury at the site. It doesn’t appear to be inflamed or swollen. You have actinic keratosis, so it might be just that, but this one particular just looks slightly different - you want to get it checked out. Otherwise no other symptoms.
If asked specifically about sun exposure, you used to work in Australia as a life coach for over 20+ years. It was always sunny when you were in Australia; you did try to put on sun cream whenever you could.
Ideas, Concerns & Expectations:
You have no idea what this is. You are concerned that this might be cancer - you have been told specifically, especially when you have fair skin, to look out for any suspicious skin lesions. You have always been careful with skin changes since you were in Australia. You would like to have this lesion removed and possibly biopsied to have skin cancer ruled out.
Past Medical History:
Actinic keratosis
Heart failure
No previous surgery
Drug History:
Furosemide
Bisoprolol
Lisinopril
NKDA
Family History:
Skin cancer runs in the family - you don’t quite remember which type of skin cancer. You just remember your mother also had quite a few black moles around her head and neck.
Social History:
Smoke ten cigarettes/day for 20 years
Drink 1-2 glasses of wine per weekend
Work as a gym owner - used to work as a life coach in Australia
Independent at home
Examination Findings:
White / Fair skin. Blonde Hair. Fitzpatrick type I-II.
Evidence of sun damage to face – with various solar elastosis, wrinkles, and cutaneous furrowing. Various actinic keratosis lesions can be seen surrounding the face and neck.
A 5mm tender, indurated hard, raised nodular keratinising lesion with ulceration/ haemorrhagic crust at the left cheek. Nonpigmentated. No pearly, rolled edge.
No lymphadenopathy. No other signs.
Differentials:
SCC - with its keratotic, ulcerated appearances and a haemorrhagic crust and PMH of actinic keratosis, this needs to be ruled.
Actinic Keratosis - usually less advanced, and this patient has had lesions which might have progressed into something more concerning
Bowen’s disease (SCC in situ) - a possibility.
Keratoacanthomas - Not always clinically distinguishable from a well-differentiated SCC.
BCC - Usually pearly papule with a rolled border and telangiectasia which this patient does not have features of.
Amelanotic Melanoma - Melanomas aren't always hyperpigmented.
Investigations:
Examine under bright, white light & measure - allows for clear examination, and measuring allows risk stratification.
Dermoscopy - allows closer inspection for clinical diagnosis and risk stratification
Serial photographing - allows to see any changes with time
Refer via urgent suspected cancer pathway to dermatology with a 2-week wait for further investigation and management.
Biopsy (guided by a specialist in dermatology):
Excisional biopsy (full thickness and well-wide margins) for histology
Consider Incisional or punch biopsy if the lesion is large, in cosmetically sensitive areas, or close to vital structures.
Reflectance confocal microscopy if available
Other Investigations for those with concerning features of malignancy:
Consider performing FBC/ LFT/ Bone Profile and other baseline bloods to assess for organ spread.
CXR should be normal except if metastases present
CT/MRI/PET Scan for spread and staging in advanced stages of cancer.
Enlarged / suspicious lymph nodes should be examined clinically/histologically by fine needle aspiration or excisional biopsy
Management: